Burnout syndrome among health care workers during the COVID-19 pandemic. A cross sectional study in Monastir, Tunisia

Background Burnout syndrome may affect the safety of frontline healthcare care workers (HCW) and patients. We aimed to measure the prevalence of burnout among HCW in care facilities in Tunisia during the Covid-19 pandemic and to identify its associated factors. Methods We conducted a cross-sectional study among HCW practicing during the covid-19 pandemic in health care facilities in the governorate of Monastir. Data collection was carried out using an anonymous self-administered questionnaire composed by three sections: epidemiological and clinical characteristics, professional conditions and the Maslach Burn out Inventory (MBI-HSS). Results This study included 371 HCW. The prevalence of burnout was 77.9% (CI 95%: 73.6% - 82.1%). The severe level was found in 71 participants (19.1%), the moderate level in 115 (31%) and the low level in 103 (27.8%). The distribution of the levels of the burnout dimensions among the participants was as follows: high emotional exhaustion (EE) (57.4%), high depersonalization (DP) (39.4%) and low personal accomplishment (22.6%). The main determinants of burnout among healthcare professionals during COVID 19 pandemic were: working more than 6 hours per day (OR = 1.19; CI95% [1.06; 1.34]), physician function (OR = 1.17; CI 95% [1.05; 1.31]), feeling a negative impact of work on family life (OR = 1.40; 95% CI [1.13; 1.73]), and high personal estimation of COVID 19 exposure (OR = 1.15; CI95% [1.02; 1.29]). Conclusion During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.


Conclusion
During the COVID19 pandemic, the prevalence of burnout among health professionals was high. It was related to hard implication in COVID 19 management. Interventions like adjusting working hours, reducing workload, and providing psychological support should be taken.

Background
The COVID-19 pandemic resulted in higher mortality than previous viral pandemics of the past four decades [1]. Health professionals were on the front line to manage this pandemic in both screening and managing positive patients regardless of their severity. Since psychological suffering may be associated with the uncertainty of a safe workplace, the World Health Organization (WHO), has emphasized, during the COVID-19 pandemic, the importance of improving the mental health and psychological well-being of health-care workers (HCW) [2]. Burnout is a syndrome conceptualized as resulting from chronic workplace stress and defined as emotional exhaustion, depersonalization, and low personal achievement [3]. The prevalence and factors associated with burnout, differed according to the socioeconomic level of the country and the culture of HCW [4]. Overcrowding in hospitals and intensive care units (ICUs) and shortages of basic equipment and consumables have led to an increased burden of COVID-19 on health systems and a greater physical and psychological impact on health care personnel, particularly in LMICs where the prevalence of burnout ranges from 2.5% to 87.9% [5,6]. In order to manage this syndrome, regardless of the pandemic, studies have shown a range of factors associated with burnout have been reported, including demographics, heavy workload, second job, inadequate exposure to resources, inadequate personal protective equipment(PPE), low level of support, job insecurity, specific job tasks, inadequate breaks or vacation time, and years of service [6,7]. In these countries, the few studies that were conducted during the COVID-19 pandemic found that increased exposure to COVID-19 patients, working in the frontlines and PPE shortages were both positively associated with burnout [8,9]. Tunisia, one of the developing countries, has been largely affected by the COVID-19 pandemic. As of January 11, 2022, the total number of COVID-19 cases has reached 756,155, with a case fatality rate of 3.4%. The inpatient rate in public and private hospitals was 10.3%, and about a quarter of patients were in ICU [10]. As a result, Tunisia has undergone an overload and saturation [11] of the health system without sufficient financial resources to protect the health care personnel.
Although a few Tunisian studies have shown that some caregivers may suffer from psychological impact such depression, anxiety, and insomnia [12][13][14], no study has yet looked at burnout among health workers during this pandemic.
We aimed to measure the prevalence of burnout among HCW in care facilities in the Monastir region during the Covid-19 pandemic and to identify factors associated with this burnout.

Study design
This is a cross-sectional study conducted among health care professionals at health facilities in the Monastir region during the Covid-19 pandemic between November 2020 and October 2021.

Study setting
Monastir Governorate is one of the twenty-four governorates of Tunisia. It is situated in the east of Tunisia. It is one of the four cities (Tunis, Sousse, Monastir and Sfax) with a hospitalouniversity vocation in the country. The total number of health professionals in Monastir is 914 physicians and 2,247 paramedical personnel. Health facilities are divided into three levels: primary, secondary, and tertiary. According to the latest update of the health card of 2019, the main state tertiary-level structure in Monastir is "Fattouma Bourguiba University Hospital ". Five other small private clinics are also tertiary. Besides, the governorate has two secondarylevel structures: the Regional Hospital of Moknine and the Regional Hospital of Ksar Hellal. The other structures are primary and consist of nine constituency hospitals and 98 basic health centers.

Study population
All health professionals practicing in tertiary, secondary, and primary health care facilities in the Monastir region were included in the study. Medical professions included medical doctors (Physicians, dentists, and medical residents). Paramedical professions included nurses, anesthesia technicians, medical biology technicians, physiotherapists, dieticians, paramedics. . .
The required sample size was calculated based on a prevalence rate of burnout syndrome of 84% [15] using the following formula: n = (z α/2 ) 2 pð1À pÞ i 2 with [z α/2 = 1,96, i= 0.05, p = estimated prevalence]. The minimum number of subjects required was then 207 health professionals.

Data collection and variable definitions
Data collection was conducted using an anonymous self-administered questionnaire. The survey questionnaire covered demographic characteristics (Age, gender, marital status, having children, chronic condition and history of Covid-19 infection), work conditions (Institution, professional category, work experience, work schedule, number of shifts per week, estimated exposure to Covid-19 during regular clinical activity, self-assessment of the effectiveness of personal protective equipment in the institution, department, working in a department that hospitalizes Covid-19 patients, close contact with Covid-19 patient. . .) and the French version of Maslach Burn out Inventory (MBI-HSS) [16] to assess the level of burnout. This psychometric instrument consists of 22 items evaluating three dimensions of burnout: Occupational exhaustion (EE) (nine items): 1, 2, 3,6,8,13,14,16,20; Depersonalization (DP) (five items) 5, 10, 11, 15, 22 and Personal accomplishment assessment (PA) (eight items): 4,7,9,12,17,18,19,21. The total score of each dimension indicates a high, moderate or low level as mentioned in Table 1 [17]. Burnout occurs if EE high, or DP high or PA low. The degree of burn out is specified as follows [16,  The reliability of the Maslach Burn out Inventory was assessed using Cronbach's Alpha Coefficient, which was 0.75 indicating the sufficient level of reliability. Cronbach's Alpha Coefficient was 0.87, 0.69, and 0.76, respectively, for Occupational exhaustion (EE), Depersonalization (DP) and Personal accomplishment (PA).

Data analysis
Data were verified and analyzed using IBM SPSS Statistics version 22.0 software. Qualitative variables were represented by numbers and percentages, quantitative variables by their means and standard deviations. To identify associated factors with burnout, univariate analysis was established using the chi-square test. The determinants of burn out were identified through multivariate analysis using Poisson regression with robust variance. The threshold for statistical significance was set at 5%.

Ethical considerations
The study was conducted under Good Clinical Practice conditions and according to ethical standards collections. Written informed consent was obtained from all participants. Protection of the privacy of research subjects as well as confidentiality of their personal information was ensured.

General and occupational characteristics
This study included 371 health professionals. The average age of the study population was 36.65 years (SD:8.95), with extremes of 21 and 62 years. Female sex was predominant (79.5%). More than two-thirds of this population felt that their function as a health professional had a negative impact on their family life. Prevalence of Covid-9 infection was 35.8% (CI95%: 30.9% -40.6%). Paramedical staff and medical residents represented the two main professional categories with respective proportions of 48% and 20.2%. Among participants, 64.4% cared for COVID-19 patients as part of their clinical activities and 47.5% considered their exposure to COVID-19 to be high, but only 42.3% felt adequately protected by personal protective equipment (PPE) in their institutions. The general and occupational characteristics of the study population are described in Table 2.

Associated factors with burnout
Factors associated with burnout in univariate analysis were: Working in Covid19 units and intensive care units (p = 0.045), daily working in a department that hospitalized positive Covid-19 patients (p = 0.007), medical professional categories (p = 0.001), the usual number of hours of work per day (p = 0.007), the number of shifts per week (p = 0.045), high personal estimate of exposure to covid-19 (p<10 -3 ) and feeling a negative impact of work during the pandemic on family life (p<10 -3 ) ( Table 3). The multivariate analysis identified four determinants of burnout among health professionals during the covid19 pandemic (Table 4)

Discussion
Our study clearly met its objectives by reporting a high prevalence of burn out during the COVID-19 pandemic with a severe level among medical residents. Predictors of burnout were medical occupational categories, a sense of negative impact of work on family life, a high personal estimate of Covid-19 exposure and excessive work hours. This study highlights the significant impact of the Covid-19 pandemic on burn out of health care professionals, as it was higher (77.9%) than that found in previous studies in Tunisia or in other LMICs [18][19][20]. Currently, during this pandemic, this prevalence is within the range assumed in studies of burnout among primary care professionals in LMICs (2.5% to 87.9%) [6].
Indeed, the COVID-19 pandemic has increased workload, guilt, stigma, lack of PPE, and has become a new health care-associated disease that may exacerbate risk factors and promote mental ill health and thus burnout among HCW [21]. In the literature, there is a difference in the prevalence of burnout between countries depending on their economic level.It was higher than those conducted in France (55%) [22] and Iran (53%) [23] and lower than that conducted in Morocco (84.44%) [15]. A global study of 60 countries reported a 51% prevalence of burnout during the COVID-19 pandemic with the highest prevalence in the USA (62%) [8,24]. This difference in prevalence between developed and developing countries could be explained by the pre-existing vulnerability of the health care system, which has been challenged by this pandemic, resulting in overwork and lack of protection for caregivers.
When considering the three dimensions of the MBI instrument, our results show high levels of of EE of 57.4%, high levels of DP of 39.4%, and low PA levels of 22.6%. These results were superior to those obtained in LMIC where the pooled prevalence of burnout among primary care professionals revealed a high level of EE of 28.1% (95% CI: 21.5-33.5), a high level of DP of 16.4% (95% CI: 10.1-22.9) and PA of 31.9% (95% CI: 21.7-39.1) [6].
According to the literature, these dimensions can account for the process of installation of burn out and therefore, the first phase of EE is already started in about half of the study population. EE reflects the emotional dimension of burnout and can be both physical and psychological, which could be explained by excessive workload and lead to reduced personal accomplishment [25]. According to our study, medical health personnel was 1.3 times more likely to develop burn out. As other Tunisian studies [13,19,20], it was clear that physicians, and in particular medical residents, were the most at risk of developing burnout syndrome. Our results were consistent with those obtained in Morocco, Iran, and the United States [16][17][18]. Several studies have highlighted the importance of this problem among physicians and explained that repeated exposure to a plethora of emotions, including the need to save the patient, feelings of failure and frustration as the patient's illness progresses, feelings of helplessness in the face of illness and associated losses, bereavement, fear of becoming ill oneself or dying, uncertainty in clinical practice, and the experience of distress contribute to the high levels of stress that physicians experience in their profession [4]. Fekih et al explained that medical residents are functioning simultaneously as both learners and caregivers and experiencing considerable challenges during the pandemic [13].
Similar to our results, multiple studies have shown that higher personal estimates of COVID-19 exposure and increased contact time with COVID-19 patients were associated with higher scores on depression and burnout scales, with a pooled RR of 1.18, 95% CI = 1.05-1.32, p = .005) [24]. In a nationwide cross-sectional survey in Turkey, it was observed that the duration of contact with COVID-19 positive patients affected residents' depression and burnout scale scores [8]. Likewise, it was observed that American medical trainees who were exposed to COVID-19 patients had higher prevalence of stress (29.4%), and burnout (46.3%) [26].
It has been reported in the literature that HCW working in front line and come into direct contact with suspected or confirmed cases of COVID-19 in hospitals are the most susceptible to this disease, and this situation has multiple negative effects on mental health [6,9].
In two studies conducted in Turkey and Saudi Arabia, more than half of the physicians reported that their greatest concern about the pandemic was the fear of transmitting the virus to their families [8,27].
Other factors of burnout, protective or not, have been found in the literature and have not been clearly identified in our study such as demographic factors (age, sex, marital and parental status.) [6]. As various studies [18,28], we found no difference in the predictors of burnout according to age and sex. Others found a higher prevalence of burnout in women and suggest that this is due to their physical and psychological vulnerability, then to a greater emotionality towards the sick and finally, the difficulty of reconciling work and family life [15,24]. Adequate PPE has been widely shown to protect against burnout (RR = 0.88, 95% CI = 0.79-0.97, p = 0.01) [24]; however, our study did not show an association. This could be explained by the fact that infection control with limited resources is a chronic problem that has been widely discussed in developing countries [29]. Factors associated with burnout in low-and lower-middle-income countries were the distance to work and having to perform tasks beyond the individual's skills. Protective factors identified were exercise, breaks, and vacation time [6].
The study had some imitations. First, it is limited to HCW in Monastir governorate and results may not be generalised to all HCW in Tunisia. However, since Monastir is one of the main four cities with a hospitalo-university vocation in the country, the three levels of care (primary, secondary, and tertiary) as well as all categories of HCW are well represented. Second, this cross-sectional study evaluated burnout at a specific time, whereas prospective cohort studies could better evaluate the impact of this pandemic on health professionals.
In the light of our results, a set of preventive measures should be recommended to mitigate burn out during pandemics especially among categories with high risk of burn out (medical staff especially medical residents). Thus, interventions should include promoting a healthy work environment; limiting the maximum number of hours and days worked consecutively and ensuring work-life balance measures (hobbies, family, and social activities). Some practitioner-focused interventions may also be recommended such as stress reduction training and relaxation techniques. On the other hand, screening for burnout syndrome appears to be periodically necessary among HCW and especially those who have high exposure to COVID-19 patients.

Conclusion
Our work has shed light on the prevalence and associated factors of burnout among health professionals in Tunisia during the covid-19 pandemic. This could help us to strengthen primary prevention strategies. These should be based on strengthening psychological training, adjusting working hours and reducing workload. Further investigations are needed to explore how HCWs´burnout may affect the quality of care during a pandemic.